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Evidence for Improving Palliative Care at the End of Life: A Systematic Review
- Karl A. Lorenz, MD, MSHS;
- Joanne Lynn, MD, MA, MS;
- Sydney M. Dy, MD;
- Lisa R. Shugarman, PhD;
- Anne Wilkinson, MS, PhD;
- Richard A. Mularski, MD, MSHS, MCR;
- Sally C. Morton, PhD;
- Ronda G. Hughes, RN, MHS, PhD;
- Lara K. Hilton, BA;
- Margaret Maglione, PhD;
- Shannon L. Rhodes, MS;
- Cony Rolon, BA;
- Virginia C. Sun, BS, MSN; and
- Paul G. Shekelle, MD, PhD
- From Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California; Southern California Evidence-based Practice Center and RAND Health, Santa Monica, California; Johns Hopkins University, Baltimore, Maryland; Agency for Healthcare Research and Quality, Bethesda, Maryland; City of Hope, Duarte, California; and Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon.
Abstract
Background: Many persons and their families are burdened by serious chronic illness in late life. How to best support quality of life is an important consideration for care.
Purpose: To assess evidence about interventions to improve palliative and end-of-life care.
Data Sources: English-language citations (January 1990 to November 2005) from MEDLINE, the Database of Abstracts of Reviews of Effects, the National Consensus Project for Quality Palliative Care bibliography, and November 2005 to January 2007 updates from expert reviews and literature surveillance.
Study Selection: Systematic reviews that addressed “end of life,” including terminal illness (for example, advanced cancer) and chronic, eventually fatal illness with ambiguous prognosis (for example, advanced dementia), and intervention studies (randomized and nonrandomized designs) that addressed pain, dyspnea, depression, advance care planning, continuity, and caregiving.
Data Extraction: Single reviewers screened 24 423 titles to find 6381 relevant abstracts and reviewed 1274 articles in detail to identify 33 high-quality systematic reviews and 89 relevant intervention studies. They synthesized the evidence by using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) classification.
Data Synthesis: Strong evidence supports treating cancer pain with opioids, nonsteroidals, radionuclides, and radiotherapy; dyspnea from chronic lung disease with short-term opioids; and cancer-associated depression with psychotherapy, tricyclics, and selective serotonin reuptake inhibitors. Strong evidence supports multi component interventions to improve continuity in heart failure. Moderate evidence supports advance care planning led by skilled facilitators who engage key decision makers and interventions to alleviate caregiver burden. Weak evidence addresses cancer-related dyspnea management, and no evidence addresses noncancer pain, symptomatic dyspnea management in advanced heart failure, or short-acting antidepressants in terminal illness. No direct evidence addresses improving continuity for patients with dementia. Evidence was weak for improving caregiver burdens in cancer and was absent for heart failure.
Limitations: Variable literature indexing for advanced chronic illness and end of life limited the comprehensiveness of searches, and heterogeneity was too great to do meta-analysis.
Conclusion: Strong to moderate evidence supports interventions to improve important aspects of end-of-life care. Future research should quantify these effects and address the generalizability of insights across the conditions and settings of the last part of life. Many critical issues lack high-quality evidence.
Article and Author Information
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Disclaimer: The views expressed herein do not represent the views of the U.S. Department of Veterans Affairs, Agency for Healthcare Research and Quality (AHRQ), or National Institute of Nursing Research.
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Grant Support: The National Institute of Nursing Research and the Agency for Healthcare Research and Quality (grant no. 290-02-0003) provided funding for this project. Dr. Lorenz was supported by a Veterans Affairs Health Services Research & Development Service Career Development Award, and Dr. Dy was supported by a K07 award from the National Cancer Institute (K07-CA096 783).
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Potential Financial Conflicts of Interest:Grants received: K.A. Lorenz (Amgen).
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Requests for Single Reprints: Karl A. Lorenz, MD, MSHS, Division of General Internal Medicine, Veterans Integrated Palliative Program, Veterans Affairs Greater Los Angeles Healthcare System, 11031 Wilshire Boulevard, Code 111-G, Los Angeles, CA 90073; e-mail, karl.lorenz{at}med.va.gov.
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Current Author Addresses: Drs. Lorenz and Shekelle: Veterans Affairs Greater Los Angeles Healthcare System, 11301 Wilshire Boulevard, Code 111-G, Los Angeles, CA 90073.
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Dr. Lynn: Center for Medicare & Medicaid Services, Office of Standards and Quality, 7500 Security Boulevard, Mail Stop S3-02-01, Baltimore, MD 21244-1850.
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Dr. Dy: Johns Hopkins Bloomberg School of Public Health, Room 609, 624 North Broadway, Baltimore, MD 21205.
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Drs. Shugarman and Maglione, Ms. Hilton, Ms. Rhodes, Ms. Rolon, and Ms. Sun: RAND Corporation, 1776 Main Street, Santa Monica, CA 90401-3208.
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Dr. Wilkinson: Western Australia Center for Cancer and Palliative Care, Edith Cowan University, Building 19, Churchlands Campus, Pearson Street, Churchlands, WA 6018, Australia.
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Dr. Mularski: Center for Health Research, Kaiser Permanente Northwest, 3800 North Interstate, WIN 1060, Portland, OR 97227.
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Dr. Morton: Research Triangle Institute, 3040 Cornwallis Road, PO Box 12194, Research Triangle Park, NC 27709-2194.
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Dr. Hughes: Agency for Healthcare Research and Quality, John M. Eisenberg Building, 540 Gaither Road, Rockville, MD 20850.
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